Reflections following the First IPHU Course in Cuenca in July 2005
David Legge, IPHU Convenor
Introduction
Rudolf Virchow (1,2) argued that “ medicine is a social science and politics is nothing else but medicine on a large scale†but, compared with our teaching of the science of healthc, health care practitioners receive very little training in the politics of health.
The International People's Health University (IPHU) aims to address this need. The first short course sponsored by the IPHU was presented in July 2005 in Cuenca, Ecuador ( 4 ), in the lead up to the Second People's Health Assembly ( 5 ). Forty seven young activists from 27, mainly developing, countries, gathered together with teachers from 13, mainly developing, countries to work through a range of topics including the political economy of health, trade and health, comprehensive primary health care, health sector reform, working with communities, conscientisation, participatory research and gender and health.
The People's Health Movement ( 6,7 ) is a network of organisations and activists in over 70 countries working in different ways to challenge the social, economic and political forces that undermine people's health, in particular, the health of poor people, most of whom live in developing countries. The IPHU was created to support the work of PHM and the hundreds of national and local health organisations which make it up. The lessons from the first IPHU short course provide clear directions for building the capacity of the broader people's movement towards heath for all.
The politics of health
Let one statistic represent the disease burden that poor people around the globe carry. Half of the world's population lives in countries with more than 100 maternal deaths per 100,000 live births (8). The figure in most rich countries is less than 10/100,000 live births; the exception being the USA and here again the excess burden is carried by the poor. Half a million young women die in childbirth each year in the high risk countries. Reducing maternal mortality involves both science and politics. There is a range of technical tools, from antenatal care to obstetric intervention and there is a domain of political struggle, from health care financing to economic development, to create the conditions to deliver effective technical services. The science and the politics of safe motherhood are entwined at all levels from the organisation of health care locally to policies for ‘health development' globally.
The disproportionate burden of disease carried by poor people and poor countries is not because the technologies of prevention and care do not exist and not because the material resources could not be made available but because of the political and economic structures (from the local to the global) which maintain an unequal and unfair distribution of opportunities and resources. At the global level the determinants of health are shaped by the prevailing regime of global governance; a configuration of power relations based on rich world governments and global corporations; hegemonic military forces (principally those of the USA); international regulatory bodies such as the World Trade Organisation and the International Monetary Fund and the shared perspectives and interests of the middle classes of both rich and poor countries.
Oppositional forces arrayed against this regime include some national governments who are challenging this prevailing dispensation plus various popular movements organised around such issues as national sovereignty, jobs the environment as well as health. Such movements are generally local in their main focus with variable intersectoral and international links. There are powerful social movements in many Third World countries which have health on their agenda or which are centrally focused on health issues and there have been some significant victories in recent years. These include delegitimating the IMF's structural adjustment packages (SAPs) because of their impact on health (9); challenging the transnational pharmaceutical companies in relation to access to AIDS/HIV drugs (10); and encouraging the WHO to engage more effectively over trade regulation and its impact on health (11).
The People's Health Movement was formed after the first People's Health Assembly in Bangladesh in 2000. It is a network of networks, linking health activists in over 70 countries and working across a range of issues but with a particular focus on primary health care and the social, economic and political determinants of health.
Health activists
‘Health activists' are people who engage in the politics of health, whether at the local or global levels. Health activists may include public health practitioners working in government or in professional organisations concerned with public health. It also includes health practitioners (and students) taking time out of their paid commitments or study to work alongside members of local communities, unions and other interest groups to create the conditions for better health. Many of these local community and interest group members also identify as ‘health activists' struggling for better health for their communities although many orient their activism around other issues such as gender equality, access to education, freedom from exploitation, adequate social security or fair prices for farm products. The struggle for health overlaps unknowably with other ways of conceiving the struggle for a decent life.
The career of the health activist commonly starts with concern over a particular issue framed in quite specific terms. This could be a midwife concerned about access to drugs for her clients, women's groups concerned about gender inequality or local practitioners concerned about nutrition. However, the more one engages at the local level the clearer the links to the national and global levels become. Access to safe drugs is related to price and to government budgets; gender inequality is reproduced through education, employment and legal exclusions; food security reflects a wider economic regime including global trade rules. These are not alternatives; the midwife does not give up struggling to procure necessary drugs in order to demonstrate against ‘TRIPS plus' (12). Rather, she finds ways of allocating her efforts across both levels or at least working with others who can share the load. Drugs, gender and food are not mutually exclusive as foci for struggle. Building a movement for change requires solidarity across these different struggles.
Curriculum for health activism
It is not surprising that many health professionals prefer not to be too involved in the politics which shape the levels of care and the programs of prevention that they deliver. The politics of health can be uncomfortable. Health activism requires that we travel beyond the secure boundaries of professional expertise. There is no singular truth about the structures and dynamics of global governance and this can be very disconcerting for those who are accustomed to the certainties of the basic sciences and evidence-based health care. For many clinicians, the scale at which the global determinants of health operate is itself disempowering; it is all too big.
It is certainly not easy. Making sense of dilapidated drug procurement or the reproduction of gender inequality or food insecurity requires visiting a range of different explanatory models (variously overlapping and inconsistent) and drawing from them a story which is specific to the immediate local challenge. Thinking through the links between the local and the global and selecting strategies which address change at different levels require considering different strategic models before deciding how to act. Health activists may draw upon a wide range of strategies from delegitimation of the IMF's SAPs through to building international solidarity around issues such as access to drugs and fair trade.
Health activists need knowledge about their field of work, local and sectoral knowledge; they need theory to inform their practice; they need experience to inform their judgement and they need communication skills to work across sectors and with grass roots people. But their work is much more than this; effective collaboration requires respect and reciprocity; an openness to trying out different ways of understanding the world; not compatible with the privileged truth of singular science. And health activists need ethical practices to protect themselves against the various seductions and easy options which may cross their path. Health activists will look in vain for such knowledges, skills, attitudes and ethical resources in the standard undergraduate courses or in most standard master of public health (MPH) courses.
The International People's Health University
The first short course presented by the IPHU (Cuenca, Ecuador, July 2005) included students from widely differing backgrounds, from indigenous women's groups to primary health care practitioners. The course was clearly successful in terms of process and impact with very positive (although not uncritical) evaluations from the student group. The participants appreciated the content regarding global determinants and health policy but some thought that there should have been a greater emphasis on the skills and strategies required for working in organisations and with communities. Participants greatly appreciated the opportunity of working with activists from different countries and settings; developing new networks and deeper cross-cultural understanding.
Looking back one year after the Cuenca course a young Ecuadoran physician, who had subsequently enrolled in an MPH, commented:
"Besides helping me to connect with people who experience the same everyday frustrations at health care units where there are no resources to provide basic medical attention or in hospitals where children die everyday because their parents have lost their jobs and similarly the frustration of seeing more and more children working in the streets of Quito (Ecuador, my country) without access to food or secure water not to mention health care ... "
"IPHU gave me the resources needed to access non-mainstream information, for example, knowing that I can explain now with evidence, articles and serious research, or examples from different communities (mainly from IPHU contacts/authors or via links provided to me by people I've met at IPHU) how the free trade agreements impact; explain why more and more children are displaced with their parents from their lands in the highlands and are forced to work in the city streets for food. ... IPHU helped me to know the People's Health Movement and to be involved. "
A young public health trainee from Australia reflecting one year on commented:
"Probably the most significant outcome of the IPHU for me was making friends and networks with like-minded colleagues from different countries; people I hope to work with and stay friends with for a long time. It has also given me a framework in which to understand our efforts in Australia but also the movement globally. ... I realise that I was so inspired by the people I met and also encouraged by knowing that I am part of a real movement. I can see now how my work might seem like a good achievement to them even though it only feels like a tiny contribution to me, particularly compared to the others! ... I think IPHU makes a big contribution to ensuring that the voices of the people who are suffering the most from the system we are struggling against are not only heard but strengthened. "
IPHU will continue to concentrate on short courses in the short to medium term, primarily in developing countries. IPHU teaching will continue to address core themes including the strengthening of primary health care (PHC) and study, advocacy and mobilisation in relation to the political and economic determinants of health. Special focus short courses will also address issues which are of concern to local activists in the regions and networks involved. IPHU is also committed to developing a strong research program as well as its teaching and is presently seeking funds for a project aimed at drawing lessons from the primary health care (PHC) experience of different countries. This project will also work to develop research capacity across the broader people's health movement.
IPHU is at an early stage. There is much to be done, including building affiliations with supportive academic centres and securing on-going funding support. However, we think that Virchow would be encouraged by the progress so far.
References
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